GeneralHospital Discharge Summary Document

Substance	Reactions	Severity	Date of onset	Comments
IVP dye	anaphylaxis	Very severe?	2010	Not sure why the patient is very unhappy when she turns green.

Condition	Code System	Code	Date of onset
Hypertension	ICD-9	401	October 21, 2009
Depression	ICD-9	331

 

Accident Type	Accident Description	Date of onset
Car Accident	Trauma...	October 10, 2010

Note: Only the the most recent three values or reports of each type are listed below:

Laboratory Results
Result	Abnormal Flag	Value	Units	Reference Range	Date/time
Mean Platelet Volume	H	12.5		(9.0-12.0)	1/26/2010 15:29
Mean Platelet Volume	R	11		(9.0-12.0)	1/26/2010 22:00
Glucose LvL	H	101	mg/dL	(70-100)	1/26/2010 15:00

 

Radiology Reports
1/26/2010 13:09
GeneralHospital PROCEDURE: ADX6544 - WRIST ROUTINE MIN 3 VIEW LT DATE OF EXAM: 26-Jan-2010 1:09PM RIS ORDER NO: 90001 CPT: HISTORY: Pain/trauma. nondisplaced fracture of the distal left radius. The remaining bones appear intact. The carpal bones are intact. IMPRESSION: Nondisplaced fracture of the distal left radius. Transcriptionist: CR2 Dictated Date: 26-Jan-2010 Transcribe Date/Time: 26-Jan-2010 2:51P Read By: Dr. Avicenna M.D. Signed By: Dr. Avicenna M.D. Professional Codes: \
1/26/2010 20:09
PROCEDURE: CDX2050 - SPINE CERVICAL COMP MIN 4 VIEW ORDERING DOCTOR: Hippocrates, Doctor M.D. DATE OF EXAM: 26-Jan-2010 8:09PM RIS ORDER NO: 90001 CPT: 72050 HISTORY: Trauma. FINDINGS: Five views of the cervical spine demonstrate normal alignment and stature of the cervical vertebral bodies. The disc spaces are preserved. The neural foramina are largely patent. Carotid vascular calcification is seen in the left neck. IMPRESSION: No acute fracture. Transcriptionist: KP1 Dictated Date: 26-Jan-2010 Transcribe Date/Time: 26-Jan-2010 11:47A Read By: Doctor Avicenna M.D. Signed By: Doctor Avicenna M.D. Professional Codes: 959.09-1403

 

Cardiology Reports
1/26/2010 12:58
GeneralHospital Berlin 100 Townsend Avenue Berlin, NJ 08009 (856)322-3000 Transthoracic Echocardiogram 2D, M-mode, Doppler, and Color Doppler Name: MR #: Account #: Study date: 26-Jan-2010 DOB: NA Age: 67 years Gender: Female Height: Weight: BSA: Cardiac : Clerk Cardiology Interpreting Cardiologist: Scott L. Avicenna, D.O. Summary: - Procedure information: This was a technically difficult study. Echocardiographic views were limited by poor acoustic window availability. - Left ventricle: Systolic function was normal by visual assessment. Ejection fraction was estimated to be 60 %. Wall thickness was mildly increased. Hypertrophy was noted. Doppler parameters were consistent with abnormal left ventricular relaxation (grade 1 diastolic dysfunction). - Aortic valve: The valve was probably trileaflet. Leaflets exhibited mildly increased thickness, normal cuspal separation, good mobility, and sclerosis. Comparisons: The previous study was not available for direct comparison. History: Consistent with transient ischemic attack or stroke. Prior history: Atrial fibrillation. Risk factors: hypertension. Diabetes. Chronic lung disease. Procedure: The transthoracic approach was used. The study included complete 2D imaging, M-mode, complete spectral Doppler, and color Doppler. Echocardiographic views were limited by poor acoustic window availability. This was a technically difficult study. Left ventricle: Size was normal. Systolic function was normal by visual assessment. Ejection fraction was estimated to be 60 %. Wall thickness was mildly increased. Hypertrophy was noted. Doppler: Doppler parameters were consistent with abnormal left ventricular relaxation (grade 1 diastolic dysfunction). Aortic valve: The valve was probably trileaflet. Leaflets exhibited mildly increased thickness, normal cuspal separation, good mobility, and sclerosis. Doppler: Transaortic velocity was minimally increased. There was no stenosis. There was no regurgitation. Mitral valve: Valve structure was normal. There was normal leaflet separation. Doppler: There was no regurgitation. Left atrium: Size was normal. Atrial septum: No defect or patent foramen ovale was identified. Right ventricle: The size was normal. Systolic function was normal. Wall thickness was normal. Pulmonic valve: Not well visualized. Tricuspid valve: Not well visualized. Doppler: There was no evidence for tricuspid stenosis. There was no regurgitation. Right atrium: Size was normal. Systemic veins: IVC: The inferior vena cava was normal in size and course. Respirophasic changes were normal. Pericardium: There was no thickening or calcification. There was no pericardial effusion. System measurement tables CW AV Env.Ti: 221.81 ms AV VTI: 33.49 cm AV Vmax: 1.8 m/s AV Vmean: 1.51 m/s AV maxPG: 12.97 mmHg AV meanPG: 9.54 mmHg PW MV A Vel: .95 m/s MV Dec Slope: 2.9 m/s2 MV DecT: 171.08 ms MV E Vel: .5 m/s MV E/A Ratio: .52 Prepared and signed by Doctor L. Avicenna, D.O.
1/27/2010 12:58
GeneralHospital Voorhees 101 Carnie Blvd Voorhees, NJ 08043 (856)325-3000 Transthoracic Echocardiogram 2D, M-mode, Doppler, and Color Doppler Patient: MR #: DOB: NA Age: 67 years Gender: Female Study date: 27-Jan-2010 Account #: Ht-Wt-BSA: 62 in- 144.8 lb- 1.67 m-? Location: VEDH-H Accession #: 4_49257 Interpreting Cardiologist: Doctor C. Hippocrates, M.D. Cardiac : Sonographer Reason for study: Assess left ventricular function. SUMMARY: - Left ventricle: - Systolic function was normal. Ejection fraction was estimated in the range of 55 % to 60 %. - Atrial septum: - There was no left-to-right shunt and no right-to-left shunt. HISTORY: PRIOR HISTORY: Patient has no history of cardiovascular disease. PROCEDURE: The procedure was performed in the echo lab. This was a routine study. The transthoracic approach was used. The study included complete 2D imaging, M-mode, complete spectral Doppler, and color Doppler. LEFT VENTRICLE: Size was normal. Systolic function was normal. Ejection fraction was estimated in the range of 55 % to 60 %. Wall thickness was normal. AORTIC VALVE: The valve was trileaflet. DOPPLER: There was no stenosis. There was no regurgitation. AORTA: The root exhibited normal size. The ascending aorta was normal in size. MITRAL VALVE: No echocardiographic evidence for prolapse. DOPPLER: There was no evidence for stenosis. There was trivial regurgitation. LEFT ATRIUM: Size was normal. ATRIAL SEPTUM: There was no left-to-right shunt and no right-to-left shunt. PULMONARY VEINS: Not well visualized. RIGHT VENTRICLE: The size was normal. Systolic function was normal. PULMONIC VALVE: DOPPLER: There was no stenosis. There was trivial regurgitation. PULMONARY ARTERY: The size was normal. DOPPLER: Systolic pressure was within the normal range. TRICUSPID VALVE: DOPPLER: There was no evidence for tricuspid stenosis. There was trivial regurgitation. RIGHT ATRIUM: Size was normal. PERICARDIUM: There was no pericardial effusion. SYSTEM MEASUREMENT TABLES 2D Ao asc: 2.5 cm CW TR Vmax: 2.1 m/s TR maxPG: 17.3 mmHg MM Ao Diam: 2.5 cm EF(Teich): 60.4 % IVSd: 0.7 cm LA Diam: 3.2 cm LVIDd: 4.6 cm LVIDs: 3.1 cm LVPWd: 0.8 cm PW E/E': 7.2 MV PHT: 60.4 ms MVA By PHT: 3.6 cm2 Prepared and signed by Doctor C. Hippocrates, M.D.

 

Transcription Reports
Consultation
1/28/2010 10:15
GeneralHospital WEST JERSEY HOSPITAL VOORHEES NJ 101 Carnie Boulevard REPORT OF CONSULTATION PATIENT NAME: Everyperson, FirstName ROOM: V5B V510P CONSULTATION DATE: 01/28/2010 M/R#: 999999 ATTENDING PHYSICIAN: CONSULTING PHYSICIAN: Hippocrates, M.D. REFERRING PHYSICIAN: REFERRING PHYSICIAN: Avicenna, M.D. Reason for Consultation: Hypertension and tachycardia. History of Present Illness: The patient is a 67-year-old female who Dr. Avicenna asked me to evaluate due to hypertension and tachycardia. She is morbidly obese, has Crohn's disease and asthma, multiple admissions for asthma and also incision and drainage of perirectal and groin abscesses. She has a history of having a catheterization in 2007 showing normal coronary arteries. Echos have shown no significant abnormalities as well. She denies chest pain, shortness of breath, PND, or orthopnea, but does have intermittent edema. Past Medical History: As above. Also with reflux, ulcerative colitis, restless leg syndrome, peripheral neuropathy, morbid obesity, carpal tunnel syndrome, hernia repair. Allergies: Avelox, Bactrim, Cipro, clindamycin, Diflucan, doxycycline, Keflex, Lamisil, oxycodone, Percocet. Medications on Admission: 1. Plavix. 2. Trileptal. 3. Prilosec. 4. Elavil. 5. Ambien. 6. Singular. 7. Requip. 8. Clonidine. 9. Pentasa. 10. Cozaar. 11. Neurontin. 12. Allegra. 13. Reglan. 14. Actos. 15. Bumex. 16. Prandin. 17. Theophylline. 18. Lantus. 19. Humulin. Review of Systems: No fever, chills, sweats, nausea, vomiting, or diarrhea. No chest pain. Positive shortness of breath with exertion. No PND, orthopnea. Positive edema, positive arthralgias. No myalgias. No neuralgias. No visual changes, hearing change, speech changes. Positive abscesses as above. No bright red per rectum, hematuria. Family History: Noncontributory. Social History: No alcohol or tobacco. Physical Examination: VITAL SIGNS: Blood pressure is 152/81 with a pulse of 127, respirations 18. She is afebrile. GENERAL: Morbidly obese female in no acute distress. HEENT: Pupils are equal, round, sclerae anicteric. Oropharynx moist mucous membranes. NECK: No JVD or carotid bruits. HEART: Normal S1, S2 without murmurs. LUNGS: Clear. ABDOMEN: Soft with normal bowel sounds. EXTREMITIES: No clubbing, cyanosis, with positive edema. NEUROLOGIC: Nonfocal. SKIN: No rash. Diagnostic Studies: Echocardiogram from last admission shows normal LV systolic function without valvular abnormality. Laboratory Studies: White blood cell count 9.3, hemoglobin 13.2, platelets of 354,000, INR 1.1, glucose 444, sodium 133, potassium 3.3, chloride 5, bicarbonate 27, BUN 18, creatinine 1. BNP of 187. This is from 01/14/10. Impression: A 67-year-old female with ulcer of colitis, asthma, and normal left ventricular function. No significant coronary disease. Admitted for possible incision and drainage of abscesses. She is on Plavix for unclear reasons. There is no cardiac indication for Plavix therapy. Her tachycardia is likely multifactorial due to her underlying pulmonary disease, and theophylline therapy as well as ongoing infection and chronic medical illness with Crohn's disease. Recommendations: 1. Check theophylline level. 2. Continue outpatient antihypertensive medical regimen including clonidine/ losartan. 3. Hold Bumex for now. 4. Replete electrolytes. 5. No cardiac contraindications undergoing surgery for abscess. 6. No need to repeat echo at this time. ________________________ Hippocrates, M.D. SS/dsk/mls 1810866 BY: / dsk DD: 01/26/2010 9:40 A DT: 01/26/2010 12:47 P cc: Avicenna, M.D. CONSULTING PHYSICIAN: Hippocrates, M.
Consultation
1/26/2010 12:58
GeneralHospital WEST JERSEY HOSPITAL VOORHEES NJ 101 Carnie Boulevard REPORT OF CONSULTATION PATIENT NAME: Everyperson, FirstName ROOM: V5B V510P CONSULTATION DATE: 01/26/2010 M/R#: 999999 ATTENDING PHYSICIAN: CONSULTING PHYSICIAN: Hippocrates, M.D. REFERRING PHYSICIAN: REFERRING PHYSICIAN: Avicenna, M.D. Reason for Consultation: Hypertension and tachycardia. History of Present Illness: The patient is a 67-year-old female who Dr. Avicenna asked me to evaluate due to hypertension and tachycardia. She is morbidly obese, has Crohn's disease and asthma, multiple admissions for asthma and also incision and drainage of perirectal and groin abscesses. She has a history of having a catheterization in 2007 showing normal coronary arteries. Echos have shown no significant abnormalities as well. She denies chest pain, shortness of breath, PND, or orthopnea, but does have intermittent edema. Past Medical History: As above. Also with reflux, ulcerative colitis, restless leg syndrome, peripheral neuropathy, morbid obesity, carpal tunnel syndrome, hernia repair. Allergies: Avelox, Bactrim, Cipro, clindamycin, Diflucan, doxycycline, Keflex, Lamisil, oxycodone, Percocet. Medications on Admission: 1. Plavix. 2. Trileptal. 3. Prilosec. 4. Elavil. 5. Ambien. 6. Singular. 7. Requip. 8. Clonidine. 9. Pentasa. 10. Cozaar. 11. Neurontin. 12. Allegra. 13. Reglan. 14. Actos. 15. Bumex. 16. Prandin. 17. Theophylline. 18. Lantus. 19. Humulin. Review of Systems: No fever, chills, sweats, nausea, vomiting, or diarrhea. No chest pain. Positive shortness of breath with exertion. No PND, orthopnea. Positive edema, positive arthralgias. No myalgias. No neuralgias. No visual changes, hearing change, speech changes. Positive abscesses as above. No bright red per rectum, hematuria. Family History: Noncontributory. Social History: No alcohol or tobacco. Physical Examination: VITAL SIGNS: Blood pressure is 152/81 with a pulse of 127, respirations 18. She is afebrile. GENERAL: Morbidly obese female in no acute distress. HEENT: Pupils are equal, round, sclerae anicteric. Oropharynx moist mucous membranes. NECK: No JVD or carotid bruits. HEART: Normal S1, S2 without murmurs. LUNGS: Clear. ABDOMEN: Soft with normal bowel sounds. EXTREMITIES: No clubbing, cyanosis, with positive edema. NEUROLOGIC: Nonfocal. SKIN: No rash. Diagnostic Studies: Echocardiogram from last admission shows normal LV systolic function without valvular abnormality. Laboratory Studies: White blood cell count 9.3, hemoglobin 13.2, platelets of 354,000, INR 1.1, glucose 444, sodium 133, potassium 3.3, chloride 5, bicarbonate 27, BUN 18, creatinine 1. BNP of 187. This is from 01/14/10. Impression: A 67-year-old female with ulcer of colitis, asthma, and normal left ventricular function. No significant coronary disease. Admitted for possible incision and drainage of abscesses. She is on Plavix for unclear reasons. There is no cardiac indication for Plavix therapy. Her tachycardia is likely multifactorial due to her underlying pulmonary disease, and theophylline therapy as well as ongoing infection and chronic medical illness with Crohn's disease. Recommendations: 1. Check theophylline level. 2. Continue outpatient antihypertensive medical regimen including clonidine/ losartan. 3. Hold Bumex for now. 4. Replete electrolytes. 5. No cardiac contraindications undergoing surgery for abscess. 6. No need to repeat echo at this time. ________________________ Hippocrates, M.D. SS/dsk/mls 1810866 BY: / dsk DD: 01/26/2010 9:40 A DT: 01/26/2010 12:47 P cc: Avicenna, M.D. CONSULTING PHYSICIAN: Hippocrates, M.

Procedure	Date
Knee Replacement	10/06/2008

Encounter Type	Location	Date	Account Number
Emergency	GeneralHospital Clinic	1/25/2010 - 1/28/2010	9898-8988

Payer Name/Contact	Priority	Group Id	Covered Party Id	Covered Party Name/Relationship	Covered Party Date of Birth
Good Health 99 Main St. Anytown, NH 978-555-1234	Primary	1111	G-0980	Everyperson, Harold M./Spouse	11/12/1944
Metropolitan Health 1 Elm St. Anytown, NH 603-555-1212	Secondary	2222	M-987987	Everyperson, Mary A./Self	7/04/1943